Transversus abdominis plane blocks in laparoscopic inguinal hernia repair: a review.

INTRODUCTION: Throughout its history, there have been significant advances in pain control of inguinal hernia repairs. One of the most recent developments is locoregional pain blocks. There is a multitude of literature available on laparoscopic inguinal hernia repair and transversus abdominis plane (TAP) blocks. OBJECTIVES: This paper seeks to provide a thorough and systematic literature review on the role of TAP blocks in laparoscopic inguinal hernia repairs. METHODS: PubMed and Google Scholar were searched for relevant literature using predetermined medical subject heading (MeSH) terms: "(TAP block)" AND "(Laparoscopic inguinal hernia repair)". RESULTS: A total of 166 publications were identified, from which 18 publications were included in the final review after eligibility criteria were applied. CONCLUSION: The majority of studies conclude that TAP blocks performed in the setting of laparoscopic inguinal hernia repair improve post-operative pain and mobility, decrease opiate analgesic usage, and are superior in pain control compared to other modalities of regional anesthesia. Thus, to improve post-operative outcomes and patient satisfaction, TAP blocks should be heavily considered for routine use in surgical practice for laparoscopic inguinal hernia repair.

Research Capacity for Prevention and Control of Non-communicable Diseases and their Risk Factors in Nepal: Findings of a Needs Assessment Study.

Background Despite a high burden, there are limited trainings in non-communicable disease research in Nepal. Objective We conducted a needs assessment to assess existing research training capacity in academic health institutions of Nepal for the prevention and control of noncommunicable diseases, identify gaps in research, and explore the feasibility of developing research training program in Nepal targeting non-communicable diseases. Method We did mixed-method research and reviewed academic institution curricula and scientific articles authored by Nepali researchers. We conducted 14 Focus Group Discussions with bachelor and masters level students of public health and community medicine; 25 In-depth Interviews with department heads and faculties, and government stakeholders. We surveyed medical and public health students on their research knowledge and skills development. Result Research methodology component was addressed differently across academic programs. One-third (33.7%) of students expressed lack of skills for analysis and interpretation of data. They felt that there is a wide scope and career-interest in non-communicable diseases research in Nepal. However, specific objectives in the curriculum and practical aspects regarding non-communicable diseases were lacking. Most of the non-communicable diseases research in Nepal are prevalence studies. Lack of funding, conflicting priorities with curative services, and inadequate training for advanced research tools were reported as major barriers. Conclusion Nepal must strengthen the whole spectrum of research capacity: epidemiological skills, research management, and fund development. Generation of a critical mass of non-communicable disease researchers must go together with improved funding from the government, non-governmental, and external funding organizations.

A National Equity Initiative to Address Noncommunicable Diseases and Injuries: Findings and Recommendation from the Nepal NCDI Poverty Commission.

We aimed to assess the burden of NCDIs across socioeconomic groups, their economic impact, existing health service readiness and availability, current policy frameworks and national investment, and planned programmatic initiatives in Nepal through a comprehensive literature review. Secondary data from Global Burden of Disease estimates from GBD 2015 and National Living Standard Survey 2011 were used to estimate the burden of NCDI and present the relationship of NCDI burden with socioeconomic status. The Commission used these data to define priority NCDI conditions and recommend potential cost-effective, poverty-averting, and equity-promoting health system interventions. NCDIs disproportionately affect the health and well-being of poorer populations in Nepal and cause significant impoverishment. The Commission found a high diversity of NCDIs in Nepal, with approximately 60% of the morbidity and mortality caused by NCDIs without primary quantified behavioral or metabolic risk factors, and nearly half of all NCDI-related DALYs occurring in Nepalese younger than 40 years. The Commission prioritized an expanded set of twenty-five NCDI conditions and recommended introduction or scale-up of twenty-three evidence-based health sector interventions. Implementation of these interventions would avert an estimated 9680 premature deaths per annum by 2030 and would cost approximately $8.76 per capita. The Commission modelled potential financing mechanisms, including increased excise taxation on tobacco, alcohol, and sugar-sweetened beverages, which would provide significant revenue for NCDI-related expenditures. Overall, the Commission's conclusions are expected to be a valuable contribution to equitable NCDI planning in Nepal and similar resource-constrained settings globally.

Determination and Evaluation of Sense of Coherence in Women in Semi-urban Nepal: A part of the Heart-health Associated Research, Dissemination, and Intervention in the Community (HARDIC) Trial.

Background Sense of coherence (SOC) is a core concept of salutogenesis which relates to individuals' overall life orientation. Stronger SOC associates with better coping strategies, better health, and better quality of life. Although the SOC-questionnaire is validated in many cultures and languages, it has not, to date, been applied in Nepal. Objective To determine and evaluate women's SOC before and after a health education intervention. Method This study was conducted as a part of the Heart-health Associated Research, Dissemination, and Intervention in the Community in the semi-urban JhaukhelDuwakot Health Demographic Surveillance Site in Nepal. Jhaukhel and Duwakot were selected as the control and intervention areas, respectively. Participants were women with children aged 1-7 years. Eight hundred and fifty-seven women before and 1,268 women after the health education intervention participated in the study. The statistical analysis was carried out with chi-square tests and one-way uni-variate ANOVA. Result Women's total SOC mean values at baseline were 51.1-57.4 and at follow up 54.4-54.9 in the intervention and control area, respectively. At baseline, SOC was significantly weaker in the intervention area compared to the control area (p < 0.001). At followup three months later, SOC was significantly stronger in the intervention area than in the control area (p < 0.001). Conclusion Nepalese women had weaker SOC than women in high-income countries, but comparable to neighboring country India with similar cultural features. Empowerment of women through community participation and health education strengthened SOC. The SOC-13-questionnaire in its Nepali version is recommended to be further evaluated.

In vitro and in vivo evaluation of a standardized Curcuma longa Linn formulation in cervical cancer.

BACKGROUND: The anti-cancer activity of phytomolecules present in turmeric or haridra (Curcuma longa Linn) extracts against cancer has been described in various 'in vitro and in vivo' studies. OBJECTIVE: In the present study, in vitro and in vivo anti-cancer and chemo-preventive activity of a new standardized Supercritical Turmeric Oil Extract (SCTOE) NBFR-03 was evaluated in cervical cancer models. METHODS AND MATERIALS: In vitro cytotoxicity of this formulation was assessed at 10, 20, 40, and 80 µg/ml concentrations, in three cervical cancer cell lines (HeLa, SiHa, ME180) using Sulforhodamine B assay. The in vivo anti-cancer activity was evaluated in two groups of female nude mice; the first one was with tumor xenograft implants and at the same time treatment was started with 96 µl/kg/day p.o. and 192 µl/kg/day p.o. NBFR-03 for three months. The second group was kept as chemoprevention group where mice were pre-treated with the formulation (96 µl/kg/day p.o.) for two weeks and injected with cancer cell suspension with continued treatment for three months. RESULTS: No cytotoxicity was seen in any cell line with the extract when compared to positive control (Adriamycin 10 µg/ml). In mice the first treatment group with tumor xenograft implants did not show any significant anti-tumor activity but showed a trend where higher dose group had smaller tumor volumes as compared to lower dose group and controls (p = 0.37 and p = 0.34 respectively). The chemopreventive group with pre-treated mice also showed smaller tumor size as compared to controls (p = 0.163). CONCLUSION: NBFR-03 turmeric oil extract showed a promising trend in mice pre-treated with NBFR-03. There is a scope for further studying the potential of this extract as complementary therapy and as a chemopreventive.

Neonatal testing leading to the identification of Bh (para-Bombay) phenotype in the mother: case report with review of the literature.

Para-Bombay is a rare phenotype with a homozygous nonfunctional FUT1 gene and a normal FUT2 gene leading to H-deficient red blood cells (RBCs) with or without ABH substances, depending on inheritance of the ABO gene. This case is about a 5-day-old male baby suffering from sepsis who required a 45-mL packed RBC transfusion. The baby's sample tested as A1B, D+ and mother's sample tested as group O, D+ with group 4 discrepancy due to ABO isoagglutinins. Further workup of the mother's sample with anti-H lectin was negative, which suggested the mother to be group Oh, D+. Antibody screening was panreactive with negative autocontrol, suggestive of anti-H. The titer of immunoglobulin (Ig)M anti-H was 64, IgG titer using dithiothreitol was 8, and anti-IH was absent. A negative adsorption and elution test suggested that RBCs were devoid of A and B antigens. The father's sample tested clearly as group A1, D+; hence, the cis-AB blood group was ruled out in the baby. The secretor study of the mother's saliva revealed the presence of B and H substances that neutralized polyclonal B and H antisera. Therefore, we concluded that the mother was of the para-Bombay (Bh) phenotype. This case highlights the importance of reverse grouping and resolving blood grouping discrepancies between mother and child-in this case because of an incongruous ABO blood type of the baby and the mother who was previously tested as group O, D+.Para-Bombay is a rare phenotype with a homozygous nonfunctional FUT1 gene and a normal FUT2 gene leading to H-deficient red blood cells (RBCs) with or without ABH substances, depending on inheritance of the ABO gene. This case is about a 5-day-old male baby suffering from sepsis who required a 45-mL packed RBC transfusion. The baby's sample tested as A1B, D+ and mother's sample tested as group O, D+ with group 4 discrepancy due to ABO isoagglutinins. Further workup of the mother's sample with anti-H lectin was negative, which suggested the mother to be group Oh, D+. Antibody screening was panreactive with negative autocontrol, suggestive of anti-H. The titer of immunoglobulin (Ig)M anti-H was 64, IgG titer using dithiothreitol was 8, and anti-IH was absent. A negative adsorption and elution test suggested that RBCs were devoid of A and B antigens. The father's sample tested clearly as group A1, D+; hence, the cis-AB blood group was ruled out in the baby. The secretor study of the mother's saliva revealed the presence of B and H substances that neutralized polyclonal B and H antisera. Therefore, we concluded that the mother was of the para-Bombay (Bh) phenotype. This case highlights the importance of reverse grouping and resolving blood grouping discrepancies between mother and child­in this case because of an incongruous ABO blood type of the baby and the mother who was previously tested as group O, D+.

A Network Thermodynamic Analysis of Amyloid Aggregation along Competing Pathways.

Aggregation of proteins towards amyloid formation is a significant event in many neurodegenerative diseases. Low-molecular weight oligomers are considered to be the primary toxic agents in many of these maladies. Therefore, there is an increasing interest in understanding their formation and behavior. In this paper, we build on our previously established theoretical investigations on the interactions between Aß and lipids (L) that adopt off-pathway fibril formation under the control of L concentrations. Our previously developed competing game theoretic framework between the on- and off-pathway dynamics has been expanded to understand the underlying network topological structures in the reaction kinetics of amyloid formation. The mass-action based dynamical systems are solved to identify dominant pathways in the system with fixed initial conditions, and variations in the occurrence of these dominant pathways are identified as a function of various seeding conditions. The mechanistic approach is supported by thermodynamic free energy computations which helps identify stable reactions. The resulting analysis provides possible intervention strategies that can draw the dynamics away from the off-pathways and potential toxic intermediates. We also draw upon the classic literature on network thermodynamics to suggest new approaches to better understand such complex systems.

Assessment of Health Service Delivery to Address Cardiovascular Diseases in Nepal.

Background A health care delivery system is the organization of people, institutions, and resources designed to deliver health services. A comprehensive study to explore cardiovascular health service delivery in Nepal is lacking. Objective This study attempted to assess Nepal's health system gap on organization and delivery of cardiovascular disease prevention and management services. Method This mixed-method study used the six building blocks of the World Health Organization health system framework: organization; access; coverage, utilization and demand; equity; quality of services; and outcomes. We conducted the desk reviews of national and international documents, performed several key informant interviews, calculated the relevant indicators, and assessed the Strengths, Weaknesses, Opportunities, and Threats of the cardiovascular health service delivery. Result We found that most of the cardiovascular services are concentrated in urban areas, and suffer from poor access, quality, utilization, and coverage in most of the areas resulting in poor health outcomes. Though the services have recently improved due to increased primary care interventions, there is scope for the development of competent human resources, advancement of technologies, development of national protocols, and improved monitoring and supervision. Improved disease system including the medical recording and reporting mechanism to incorporate and reflect the true burden of CVD in Nepal is lacking. Conclusion Despite having health facilities from grassroots to the central level, availability, access, and quality of cardiovascular health services are poor. Further improvement and equitable expansion of promotive, preventive, diagnostic, referral, and rehabilitative cardiovascular services are needed to ensure universal health coverage.

Environmental quality monitoring and impact assessment of solid waste dumpsites in high altitude sub-tropical regions.

Solid Waste Management (SWM) in high altitude regions is critically phased because of the non-availability of suitable facilities for the treatment and handling of large quantities of Municipal Solid Waste (MSW). Open burning practices at hill slopes were noticed which affect the surrounding environment. Hence, it became essential to measure the environmental components around the dumpsites to examine the impacts and suggest new technological solutions. The pollution parameters were monitored in and around the dumpsites, and the data was analysed using statistical tools. The assessment of air quality indicated maximum fine suspended particulate matter (PM2.5) concentration of 206.66 µg/m3 followed by respairable particulate matter (PM10), oxides of nitrogen (NOx) and sulphur dioxide (SO2). Among the gaseous emissions, methane (CH4) concentration was very high (38.53 mg/L) followed by carbon monoxide (CO) concentration (0.96 mg/L). Volatile organic compounds (VOCs) were also detected at few dumpsites with highest observed benzene (C6H6) concentration of 157.53 µg/m3. The soil sample analysis indicated that iron (Fe) concentration dominates followed by manganese (Mn), zinc (Zn), chromium (Cr), copper (Cu), and nickel (Ni). For evaluation of different alternatives for the SWM system, Rapid Impact Assessment Matrix (RIAM) was applied.

Kinetic evaluation for rapid degradation of dimethylamine enriched with Agromyces and Ochrobactrum sp.

Dimethylamine (DMA) possesses an obnoxious odor which has resulted in public concern during the past several decades. A rare bacterial species proficient to degrade DMA, designated IR-26, was isolated from Indian Oil Corporation Limited (IOCL) and identified as Agromyces and Ochrobactrum sp., which has presented a rapid degradation when compared to other bacterial species which were capable to degrade DMA. The removal efficiency of 100% has been calculated in different concentration of DMA. The kinetic study reveals the maximum reduction rate of DMA was 0.11 per hour and the maximum growth rate of biomass was 0.013 per hour respectively. The saturation constant of DMA was around 1.96 mg/L which shows a high affinity of DMA. The importance of these analyses is offered and conversed in this paper.

A longitudinal study of altered taste and smell perception and change in blood pressure.

BACKGROUND AND AIMS: Previous studies suggest that olfactory receptors, which mediate smell chemosensation, are located in the kidney and involved in blood pressure regulation. Mammalian epithelial sodium channels located in taste receptor cells are also found to participate in blood pressure regulation. However, there is currently no human study that has examined the association between taste and smell function and blood pressure. We thus conducted a longitudinal study to examine whether participants with altered taste and smell perception had larger increases in blood pressure compared with those without altered perception in a community-based cohort. METHODS AND RESULTS: The study included 5190 Chinese adults (4058 men and 1132 women) who were normotensive at baseline. Taste and smell perception were assessed via questionnaire in 2012 (baseline). Blood pressure was measured in 2012 and 2014 to determine relative change in blood pressure. Mean differences of 2-year blood pressure change and 95% confidence intervals (CIs) across four categories of taste and smell perception were calculated after adjusting for known risk factors for hypertension. After adjusting for potential confounders, individuals with altered taste and smell perception had larger increases in systolic blood pressure (adjusted mean difference = 5.1 mmHg, 95% CI: 0.1-10.0, p-value: 0.04) and mean arterial pressure (adjusted mean difference = 3.8 mmHg, 95% CI: 0.4-7.1, p-value: 0.03) after two years of follow-up compared with those having neither altered taste nor altered smell perception. No significant association was observed in individuals with altered taste or smell perception only. CONCLUSION: Our results suggest an association between chemosensory function and blood pressure.

Recent advancements in the mitigation of obnoxious nitrogenous gases.

Nitrogenous gaseous emissions commonly have an obnoxious odor associated with it, which when discharged into the environment results in serious environmental problems and health hazards. Several strategies for mitigation of nitrogenous odorants have been reported which include physical, chemical and biological methods. Biological treatments are widely employed because of their efficiency even at low concentration, where physical and chemical methods are not effective. Most commonly used biological treatment methods are biofiltration, biotrickling filters and membrane bioreactors with innovative reactor design, mixing pattern, and air sparging, for example FEBR, ALR, etc. These treatment methods require a critical assessment for the mitigation of obnoxious nitrogen emissions, especially in the context of environmental protection. This review offers a critical evaluation of treatment methods for the mitigation of nitrogenous odorous compound with a key emphasis on biological treatment systems. Also, various mathematical modelling techniques required for optimized operation of biotreatment systems has been discussed.

Antidiabetic activity of extracts of Anacardium occidentale Linn. leaves on n-streptozotocin diabetic rats.

Anacardium occidentale L. (Anacardiaceae) is used in South Cameroon as well as in other tropical countries by traditional practitioners as a folk remedy for treatment of diabetes mellitus. We demonstrated the antidiabetic potential of the plant extracts in n-streptozotocin diabetic rats. The aim of the current study was to investigate the antidiabetic effects of ethanol extract of leaves of A. occidentale on neonatal streptozotocin diabetic rats. Two day old neonates were injected with 100 mg/kg of streptozotocin. At the end of the experimental period of 30 days, reduction in the fasting blood glucose levels, serum insulin, glycated hemoglobin levels, serum lipid parameters, and renal function biomarkers were estimated in the control and treated rats. Histopathological examination of liver, kidney and pancreas were also carried out. On administration of 100 mg/kg of plant extract, blood glucose levels of the rats showed 8.01% and 19.25% decrease in the fasting blood glucose levels on day 15 and day 30, respectively. The administration of extract showed that the effects of extract treatment are comparable to treatment with the standard drug Pioglitazone. These results demonstrate significant antidiabetic potential of the ethanol extract of leaves of A. occidentale, justifying the use of plant in the indigenous system of medicine. Further studies for investigating the specific compound(s) responsible for such beneficial role in diabetes would open new outlook in the therapy of type 2 diabetes.

Menopausal Health Status of Nepalese Women.

INTRODUCTION: Menopause is an unavoidable and sometimes problematic condition in which women may suffer from a number of health problems. Knowledge of the major symptoms associated with menopause helps reduce the burden and stress associated with the condition. In this context, a study was conducted to establish baseline data regarding menopausal health problems among Nepalese women. METHODS: A descriptive cross-sectional study was conducted among 2000 women aged over 40 years to identify their knowledge, attitude and practice related to menopausal health problems. Data was collected by interviewing the women and doing physical examination. Analysis was done using descriptive statistics and SPSS software was used for data analysis. RESULTS: A cohort of 2073 women (ages 40-60 years) participated in the research, among them 2000 yielded complete response. The study revealed that 820 (41%) women had reached menopause. The average age of menopause was 48.7 years. Majority of the women 1183 (59.2%) in the study did not know about menopausal health problems. Abnormal bleeding 353 (17.65%), sweating 315 (15.75%), hot flushes 299 (14.95%), joint/muscle pain 285 (14.25%) were the most common menopausal symptoms known by the women. Joint pain 736 (36.8%), hot flushes 584 (29.2%), irregular bleeding 582 (29.1%) were the most common experienced symptoms of menopause and only 586 (29.3%) consulted the health workers to alleviate menopausal symptoms. Moreover, most of the women 926 (46.3%) accepted menopause as a part of life. CONCLUSIONS: The research has tried to establish the baseline of menopausal health problems in the Nepalese women. The average age of menopause was 48.7 years. Majority did not know about menopausal health problems. Further researches with nationally representative sample are recommended to further explore the menopausal health problems of Nepalese women.

Household food insecurity is associated with low interferon-gamma levels in pregnant Indian women.

SETTING: Over 20% of tuberculosis (TB) cases during pregnancy occur in India. OBJECTIVE: To determine the association between household food insecurity and interferon-gamma (IFN-γ) levels in pregnancy. DESIGN: Pregnant women in India were administered the Household Food Insecurity Access Scale (HFIAS) questionnaire and underwent an IFN-γ release assay. Logistic regression was used to identify factors associated with food insecurity. RESULTS: Of 538 women, 60 (11%) had household food insecurity, 47 (78%) of which were moderate or severe food insecure. After mitogen stimulation, moderate or severe food insecure women had a median IFN-γ concentration of 4.2 IU/ml (IQR 2.2-9.8) vs. 8.4 IU/ml (IQR 3.0-10) in women with no or mild food insecurity (P = 0.03). In multivariate analysis, higher IFN-γ concentrations were associated with human immunodeficiency virus infection (OR 1.3, 95%CI 0.51-2.1, P = 0.001), and inversely associated with moderate or severe food insecurity (OR -1.6, 95%CI -2.9 to -0.27, P = 0.02) and the number of adults in the household (OR -0.08, 95%CI -0.16 to -0.01, P = 0.03). There was no association between food insecurity and IFN-γ response to Mycobacterium tuberculosis antigen. CONCLUSION: Food insecurity in pregnancy is associated with low IFN-γ levels. There was no association between food insecurity and IFN-γ response to M. tuberculosis antigen, but our study was underpowered to detect this outcome.

The Heart-health Associated Research, Dissemination and Intervention in the Community (HARDIC) Trial for Nepalese Mothers regarding Diet and Physical Activity: A Process Evaluation.

Background Mothers with young children in the peri-urban Jhaukhel-Duwakot Health Demographic Surveillance site of Bhaktapur district have misconceptions and poor behavioural practice regarding diet and physical activity. We developed the Hearthealth Associated Research, Dissemination and Intervention in the Community trial - a health promotion intervention for mothers. Objective The objective of this study was to evaluate the intervention's feasibility, acceptability, potential for transferability and scaling up, and to determine its immediate outcome. Method Duwakot and Jhaukhel were randomly selected as the intervention and control communities, respectively. We trained 47 peer mothers from Duwakot, each of whom gave classes with 10 fellow mothers of their neighbourhood. The process evaluation was carried out on a continuous basis at different points of the intervention held from August to November 2016. Result In round one, the participation and completion rates were both > 90% for peer mothers; and 85% and 70%, respectively, for the fellow mothers. However, the participation rates fell in the round two of the intervention. On the whole, the mothers expressed satisfaction and acceptance of the course content and training modality. Immediate evaluation of the intervention showed improvement of knowledge, attitude and practice of diet and physical activity among both groups of mothers. Conclusion The successful implementation of the intervention targeting diet and physical activity clearly demonstrates the feasibility of health promotional activities in the Nepalese community for improvement of cardiovascular health.

In vitro macrophage activation: A technique for screening anti-inflammatory, immunomodulatory and anticancer activity of phytomolecules.

Macrophage activation plays a significant role in homeostasis of organisms. Various internal and external stress factors may affect their function, leading to adverse effects on the body. 'In vitro macrophage activation techniques provide us with a window to understand the mechanisms of inflammation and response of macrophages to the modulating interventions. Apart from infectious diseases, inflammation is also the major culprit in pathogenesis of many noncommunicable diseases such as arthritis, obesity, metabolic syndrome, diabetes, cancer, cardiovascular disease etc. In vitro macrophage activation allows us to study the role of polarized macrophages in the process of pathogenesis. This emerging technique leads to newer diagnostics, understanding pathophysiological mechanism/s, drug development and management of chronic inflammatory diseases. We, at MRC-KHS, use this technique for screening of medicinal plant-derived phytomolecules for their anti-inflammatory, immunomodulatory and anticancer activities. This review briefly outlines the different experimental models of in vitro macrophage activation and their applications for understanding the pathophysiological mechanisms of underlying chronic inflammation and screening of therapeutic activity of plant-based phytomolecules.

Characterization of municipal solid waste in high-altitude sub-tropical regions.

Solid waste management (SWM) is one of the most challenging issues owing to lack of authentic data on different elements of SWM, namely, storage, collection, transportation, separation, processing and disposal. This study presents an assessment of existing status of SWM in conjunction with municipal solid waste (MSW) generation rates, physical and chemical characterization of MSW in high-altitude sub-tropical regions. Weighing of empty and fully loaded trucks per trip revealed total quantity of MSW collected. The average efficiency of MSW collection was 70%. From the baseline data, it is inferred that the population and MSW generation rates are not co-related. The collected MSW included biodegradables (organic wastes), paper, plastic, glass, ceramics, metals, inert materials, ash and debris. The data analysis indicated that the biodegradable components dominate the characterization at 54.83% followed by inert, ash and debris at 21.06%, paper at 8.77%, plastic at 8.18%, glass and ceramics at 4.45% and metals at 2.71%. Statistical measures were also applied and 90% confidence interval (CI) was generated for the characterization data measuring its statistical significance.

Abdominal Wall Transplantation: Skin as a Sentinel Marker for Rejection.

Abdominal wall transplantation (AWTX) has revolutionized difficult abdominal closure after intestinal transplantation (ITX). More important, the skin of the transplanted abdominal wall (AW) may serve as an immunological tool for differential diagnosis of bowel dysfunction after transplant. Between August 2008 and October 2014, 29 small bowel transplantations were performed in 28 patients (16 male, 12 female; aged 41 ± 13 years). Two groups were identified: the solid organ transplant (SOT) group (n = 15; 12 ITX and 3 modified multivisceral transplantation [MMVTX]) and the SOT-AWTX group (n = 14; 12 ITX and 2 MMVTX), with the latter including one ITX-AWTX retransplantation. Two doses of alemtuzumab were used for induction (30 mg, 6 and 24 h after reperfusion), and tacrolimus (trough levels 8-12 ng/mL) was used for maintenance immunosuppression. Patient survival was similar in both groups (67% vs. 61%); however, the SOT-AWTX group showed faster posttransplant recovery, better intestinal graft survival (79% vs. 60%), a lower intestinal rejection rate (7% vs. 27%) and a lower rate of misdiagnoses in which viral infection was mistaken and treated as rejection (14% vs. 33%). The skin component of the AW may serve as an immune modulator and sentinel marker for immunological activity in the host. This can be a vital tool for timely prevention of intestinal graft rejection and, more important, avoidance of overimmunosuppression in cases of bowel dysfunction not related to graft rejection.